"EMERGENCY PSYCHIATRY DRA RONDAIN"
EMERGENCY PSYCHIATRY DR. ELIZABETH ESPINOSA - RONDAIN Emergency Psychiatry The physician deals with situations for which immediate therapeutic intervention frequently is necessary. Elements that constitute the pattern of excellent emergency psychiatric care and crisis intervention include. 1. Immediate response to patient’s needs 2. Empathy 3. Identification of precipitating events. 4. Past personal, family and psychiatric history 5. Medical history 6. Mental status examination 7. Vital signs 8. Medical examination and neurological exam. 9. Laboratory other clinical diagnostic studies 10. Contact with therapist or psychiatrist 11. Proper use of restraints if indicated and documentation of reasons for use. 12. Contact with significant others for further information 13. History of allergy 14. Proper disposition 15. Obtaining proper laboratory tests before starting psychopharmacology 16. Proper medication for the illness It is important to formulate a tentative diagnosis and differential diagnosis to guide treatment. A. Medical and Psychological Conditions That may Present with Violent Behavior Acute alcoholic intoxication Central nervous system neoplasms Delirium Delirium tremens Side effects of barbiturate, tricyclic, tetracyclic, and benzodiazepine therapy Temporal lobe epilepsy Acute schizophrenic episode Antisocial personality Borderline personality Catatonic excitement Dissociative states Homesexual panic Narcisistic personality Schizophrenia, especially paranoid schizophrenia Important Considerations in Diagnosis of a Violent Behavior in Patient 1. Patient’s premorbid personality 2. Past history 3. The underlying disorder 4. The social setting B. Physical and Psychological Conditions That Present with altered Mood. Important Considerations in the Diagnosis of Mood Disturbance in a Patient 1. Nature of the psychiatric and medical illness 2. Genetic predisposition 3. Developmental history 4. Individual characteristic pattern of defense. Physical Conditions That May Present With Altered Mood. Alcohol intoxication Antihypertensive medication (e.g., methyldopa, propranolol, reserpine toxicity) Antidepressant medication Benzodiazepine intoxication Carcinoma of pancreas Cerebral tuberculosis Cerebrovascular syphilis Cessation of amphetamine or cocaine use Cirrhosis of the liver Corticosteroid toxicity Degenerative diseases of the central nervous system (e.g., Alzheimer’s disease, Huntington’s chorea, Pick’s disease) Diabetes Encephalitis Hepatic failure Hepatitis Hyperparathyroidism Hyperthyroidism Hypokalemia Hyponatremia Hypothyroidism Infectious mononucleosis Multiple sclerosis Postviral infection syndrome Renal failure Subdural hematoma Psychological Conditions that May present with Altered Mood Acute schizophrenia Bipolar mood illness Catatonic schizophrenia Chronic schizophrenia Reactive depression Reactive psychosis Schizoaffective schizophrenia C. Physical and Psychological illness that Present with Anxiety Alcohol withdrawal Aminophylline use Amphetamine and similar sympathamimetic Antidepressant withdrawal Antipsychotic drug withdrawal Benzodiazepine withdrawal Caffeine intoxication Delirium Encephalitis Hypertension Hyperthyroidism Hypocalcemia Hypoglycemia Hypokalemia Impending myocardial infarction Internal hemorrhage Lead intoxication Opiate withdrawal Postconcussion syndrome Temporal lobe disease Psychological Conditions that May Present with Anxiety Adjustment disorder with anxious mood Agoraphobia with panic attacks Agoraphobia without panic attacks Bipolar mood illness Borderline personality Ego-dystonic homosexuality Generalized anxiety disorder Homosexual panic Hyperventilation syndrome Obsessive-compulsive disorder Post-traumatic stress disorder Schizophrenia Social phobia D. Physical and Psychological Conditions That Present with Disorganization of Thought Alcohol withdrawal Amphetamine intoxication Anticonvulsant withdrawal Antidepressant medication Bacterial meningitis Cocaine intoxication Corticosteroid toxicity Delirium Hyperparathyroidism Hyperthyroidism Hypoparathyroidism Hypothyroidism Lead intoxication Mercury intoxication Migraine headache multiple sclerosis Steroid toxicity Subdural hematoma Systemic lupus erythematosus Temporal lobe epilepsy Psychological Conditions that May Present with Disorganization of Thought Adjustment reaction of adolescence Bipolar mood illness Catatonic schizophrenia Chronic undifferentiated schizophrenia Paranoid schizophrenia Reactive psychosis Schizoaffective disorders Schizophreniform disorders How to approach a Patient in an Emergency Condition A. Emergency Psychiatric Interview Important Considerations. 1. Focus on the presenting complaints and reasons on why the patient has come to the emergency room. 2. Time constraint – structure the interview 3. Get supplemental history from relatives and companions. 4. Psychiatrist should be honest, calm, direct non-threatening and in control of the situation. General Strategy in Evaluating Patients I. Self-protection A. Know as much as possible about the patients before meeting them. B. Leave physical restraint procedures to those who are trained to handle them. C. Be alert to risks for impending violence. D. Attend to the safety of the physical surrounding (e.g., door access, room objects). E. Have another person present during the assessment if needed. F. Have others in the vicinity. G. Attend to developing an alliance with the patient (e.g., do not confront or threaten patients with paranoid psychoses). II. Prevent harm A. Prevent self-injury and suicide. Use whatever methods are necessary to prevent patients from hurting themselves during the evaluation. B. Prevent violence toward others. During the evaluation, briefly assess the patient for the risk of violence. If the risk is deemed significant, consider the following options. 1. Inform the patient that violence is not acceptable. 2. Approach the patient in a nonthreatening manner. 3. Reassure and Calm the patient or assist in reality testing. 4. Offer medication. 5. Inform the patient that restraint or seclusion will be used if necessary. 6. Have teams ready to restraint the patient. 7. When patients are restrained, always observe them closely, and frequently check their vital signs. Isolate restrained patients from agitating stimuli. Immediately plan a further approach-medication, reassurance, medical evaluation. Features That Point to a Medical Cause of Mental Disorder Acute onset (within hours or minutes, with prevailing symptoms) first episode Geriatic age Current medical illness or injury Significant substance abuse Nonauditory disturbance of perception Neurological symptoms-loss of consciousness, seizures, head injury, change in headache pattern, change in vision Classic mental status signs-diminished alertness, disorientation, memory impairment, impairment in concentration and attention, difficulty in calculation, concreteness Other mental status signs-speech, movement, or gait disorders Constructional apraxia-difficulties in drawing clock, cube, intersecting pentagons, bender gestalt design. Management of Functional Psychoses 1. Make sure that the patient is not likely to hurt someone or flee before an evaluation can take place. 2. Decide if immediate use of medication is advisable. 3. Engage the patient so that signs and symptoms as well as recent critical events can be adequately assessed 4. Determine if the problem is organic or functional. 5. Establish if the patient is psychotic or not psychotic. 6. Decide if the patient’s primary problem is a thinking or a mood disorder. 7. Evaluate if patient is for hospitalization. 8. In form the relatives regarding the disposition of the patient. Assessment and Management of the Violent Patient Predictions of Potential Violent Behavior. 1. Excessive alcohol intake 2. History of violent acts with arrests or criminal activity 3. History of childhood abuse 4. Verbal or physical threats 5. Carrying weapon or other objects that might be used as weapon (forks, broken glass) 6. Prescence ofcommand violent auditory hallucination 7. Paranoid features in a psychotic patient. Management of Violent Patients 1. Medications – psychotropic intramuscular medication like haloperidol or diazepam. 2. Physical restraint – used when patients are so dangerous to them selves and to others. Rape and Sexual assault Rape an unexpected and violent threat on one’s life. it is a loss, violation and instant demoralization. typical reactions include shame, humiliation, anxiety, confusion and out rage. Management 1. A psychiatrist, counselor or a trained clinical staff should stay with the patient the entire time in the E.R. 2. Give the patient explanations for specific data that is needed. 3. The patient must be asked for consent for examination and specimen collection 4. Be patient and considerate. Never press or harass the patient for answers. 5. Answer the patient’s questions and frequent reassurance that the patient is in a safe place. 6. The patient must be given time and date to make her own decision about the legal process. 7. Educate the patient about the rape trauma syndrome. 8. Call the patient 48hours later and then weekly for follow up. 9. On later stages, provide counseling with realistic issues such as work, home, legal difficulties, sharing of emotion, future rehabilitation. SUICIDE SUICIDE the conscious decision to end one’s life Among the top ten causes of death in western countries Occurs in all ages, racial/ethnic groups More women than men attempt suicide though men are more successful with their attempts Suicide rate in children in the west have tripled since 1985 According to the American Association for Counseling and Development, suicide is the 2nd leading cause of death among children and adolescents in the U.S. RESEARCH ON SUICIDE World Health Organization - estimates self inflicted acts are related to 64% of deaths under age 25 - most number of suicides are in first world countries (25 out of 100,000 people - least number of suicide reported : Spain, Italy, Ireland and Egypt (10 out of 100,000 people) Philippines - completed suicide usually between age 18-27 years old - method: hanging and poisoning - 37% of suicide attempts are completed - as of 1996, 902 suicide attempts were reported in Metro Manila, 331 of these were completed - usually occurs during Christmas time, opening of school, February United States - 30,000 deaths each year are attributed to suicide - suicide attempts are estimated to be 8 to 10 times more - in the past 30 years, there is an increase in suicide among 15 to 24 years old considered the 3rd leading cause of death in this age group - among 25 to 44 year olds, it is the 4th leading cause MYTHS ON SUICIDE People who talk about or threaten suicide don’t really mean it Suicides frequently occur out of the blue or without forewarning According to Robert Cancro, MD of NYU Medical Center: - Schizophrenics tend to attempt suicide early in their illness before age 25 - Diagnosed schizophrenics have a high rate of suicide, up to 20x of normal suicide rates - Manic depressives also have high rates of suicide -Alcoholism by itself tends to promote suicide - Alcoholism among parents may be a factor among youth suicides - NIHM says an estimated 15% of untreated depression commit suicide Suicide runs in the family Suicidal person want nothing more than to die Once suicidal, always suicidal Uncompleted suicides won’t try again because of shame All suicides leave notes Cluster suicides are on the increase (copycat suicides) Most suicide occur at night time More suicides occur during the holidays Women threaten suicide while men go through with it Celebrities are more prone to suicide than the general population DYNAMICS OF SUICIDE Freud’s Psychoanalytic Theory - suicide is triggered by an intrapsychic conflict that emerges when person experiences great psychological distress. b) Durkheim’s Sociological Approach - social pressures and influences are major determinants of suicidal behavior ASPECTS OF SUICIDE Situational Conative Affective Cognitive Relational Serial RISK FACTORS FOR SUICIDE If the client has… Family history of suicide History of previous attempts Formulated a specific plan Family is destabilized due to loss, personal abuse, violence Psychosis History of drug and/or alcohol abuse Serious depression, coming out of depression or recently hospitalized for depression History of unsuccessful medical treatment or recent physical trauma Lives alone and cut off from others Give away prized possessions Radical shifts in characteristic behaviors or moods Pervasive feelings of hopelessness/helplessness Preoccupied or troubled by earlier episodes of experienced physical, emotional or sexual abuse Exhibits profound degree of one or more emotions of anger, aggression, loneliness, guilt, hostility, grief or disappointment RISK FACTORS FOR SUICIDE AMONG PERSONS BETWEEN AGE 15 - 24 Family history of alcohol and drug abuse Family breakdown Troubled family with poor communication and dysfunctional boundaries Symptoms of delinquency, aggression and depression Nonspecific crisis Impulsive response to crisis or loss Know someone who committed suicide Substance abuse Feel expendable Sense of hopelessness about sexuality Isolated, without support groups SUICIDE CLUES High feeling of ambivalence or inner conflict Call for help in some way – usually indirect Hints about problems Verbal clues Behavioral clues Situational clues Syndromatic clues Sudden appearance of happiness and calmness after a period of some of the characteristics listed above WHAT A PHYSICIAN CAN DO Do not hesitate to ask questions such as “Are you thinking of killing yourself?” “how, when and where?” Refer to a psychiatrist for co- management Contact family and other support of client With Children and Adolescents Trust your suspicions Tell the person that you are worried about him, listen to what he has to say Ask direct questions, don’t act shocked at what he tells you Don’t debate on whether it is right or wrong Don’t promise to keep youngster’s intention secret Don’t leave youngster alone if you think risk is immediate Get help from a psychiatrist and other responsible adult Ensure youngster’s safety Assure child something is being done Assume active authoritarian role as needed to protect the person at risk After risk is overcome, monitor the child closely – many suicide attempts recur three months after initial attempt With Adults Client safety is primary Help client discover his ambivalence Help him clarify and understand current conflict Use history taking to evaluate client’s developmental background and show how current suicidal crisis evolved Assist client to 1) separate thought from action 2) reinforce expression of affect 3) anticipate consequences of action 4) focus on precipitating events and constructive alternative Provide clear cut and appropriate referral sources Interview family to evaluate existing support system DON’TS IN COUNSELING SUICIDAL CLIENTS Don’t lecture, blame or preach Don’t criticize client Don’t debate the pros and cons of suicide Don’t be misled by client’s telling you the crisis has passed Don’t deny the client’s suicidal ideas Don’t try to challenge Don’t leave client isolated, unobserved or disconnected Don’t diagnose and analyze behavior or confront person with interpretations during acute phase Don’t be passive Don’t over react Don’t keep client’s suicidal risk a secret Don’t get side tracked on external issues or persons Don’t glamorize, martyrize, glorify or defy suicidal behavior in others, past or present Don’t forget to follow up REFERENCES: Kaplan and Sadock, Synopsis of Psychiatry 10th Edition Psychiatric Emergencies Edited by: William R. Dublin, M.D. Nancy Hanke, M.D. Herbert W. Nickens, M.D., M.A Thank you . . . .